PSB-04A - Texas Department of Public Safety

Texas Department of Public Safety MUST USE MOST CURRENT FORM PRIVATE SECURITY
Regulatory Services Division
PRINT CLEARLY IN BLACK INK
EXAMPLE:
MAKE SURE ENTIRE CIRCLE IS FILLED
www.dps.texas.gov
Yes
•
No ◦
ORIGINAL OWNER / MANAGER APPLICATION
APPLICATION INFORMATION
I understand that only one type of owner/manager can be applied for with this Yes ◦
form and that if I select more than one on this form that my application will NOT
No ◦
be processed and will be returned to me.
THE ABOVE SPACE IS RESERVED FOF OFFICE USE ONLY
TYPE OF APPLICATION (CHECK ONLY ONE)
Description Original Fee + Subscription Fee = Total
◦Owner, Officer, Partner, Shareholder $50 + $5 = $55
◦Owner, Officer, Partner, Shareholder / Manager $50 + $5 = $55
◦Owner, Officer, Partner, Shareholder / Supervisor $50 + $5 = $55
◦Manager Only $30 + $3 = $33
◦Supervisor Only ** $30 + $3 = $33
** Supervisor applicants must meet the requirements of Texas Occupations Code 1702.119 (c).
Note: If replacing a manager for a licensed company in the state of Texas, please refer to the link provided for additional instructions:
www.txdps.state.tx.us/psb/docs/InstrForReplacementMgr.pdf
APPLICANT INFORMATION
Company
Name
Applicant Social
Security Number - -
Applicant
Last Name
Home
Address
City
Date of Birth
(MM/DD/YYYY) / /
Gender Male ◦ Female ◦
Eyes
State
(2- Digit Code)
Place
of Birth
◦
◦
TX Driver License
TX ID Card
First
Name
ZIP
Company
License No.
DL/ID
No.
M.I.
Home
Phone ( )
(CITY) (STATE) (COUNTRY)
Suffix
(If Any)
◦1. Blue ◦ 2. Brown ◦ 3. Gray ◦ 4. Hazel ◦ 5. Green ◦ 6. Black
Height Ft. In.
Weight
List any alias
you have used:
Describe
Your Duties:
Lbs.
Hair
Race
◦ 1. Black ◦ 2. Red ◦ 3. Gray ◦ 4. Brown ◦ 5. Blonde ◦ 6. Bald
◦ 1. White ◦ 2. Black ◦ 3. Spanish ◦ 4. American
Indian
◦ 5. Asian ◦ 6. Other
_______
PAYMENT INFORMATION
I am submitting the appropriate fee(s) with this application by mail.
(Note: Payment must be in the form of a cashier’s check, money order or company check.)
PSB-04A (Rev. 12/2012) Page 1 of 2 FORM
Yes
No
◦ *If yes, a PSB-50 form must be submitted with this application.
◦
I understand that all fees submitted to Private Security are non-refundable, are not transferable and that, in accordance with
Administrative Rule 35.77, I will have 90 days from the date the application is received by the Department to turn in all required
documentation, supplemental information and/or fees OR this application will be abandoned and I will be required to reapply.
SUPPLEMENTAL INFORMATION (REQUIRED WITH THIS APPLICATION)
Regarding submitting Fingerprints: (CHOOSE ONLY ONE)
◦ I am submitting two (2) classifiable, Board approved fingerprint cards along with the $25 FBI classification fee.
◦ I submitted fingerprints electronically and am attaching my signed IBT FAST receipt as proof with this application.
◦I am a Peace Officer (or Retired Peace Officer) alternatively submitting a PSB-49 (Peace Officer Fingerprint Waiver) form with this application,
instead of FBI fingerprint cards.
Yes
No
◦
◦

Applicant
Name
Social
Security No. - -
BACKGROUND INFORMATION
1. Have you ever been convicted, in any jurisdiction, of a felony level
offense?
Yes
No
◦* If yes, has it been LESS than ten (10) years since completing your
sentence or probationary period?
◦
Yes
No
◦
◦
2. Have you ever been convicted, in any jurisdiction, of a Class A or Yes ◦* If yes, has it been LESS than five (5) years since completing your Yes ◦
equivalent misdemeanor?
No sentence or probationary period?
◦
No ◦
3. Have you, within the past 5 years, been convicted, in any jurisdiction, of a Class B misdemeanor or equivalent offense? Yes ◦ No ◦
4. Are you currently charged with, or under indictment for, a felony, or Class A misdemeanor? Yes ◦ No ◦
5. Are you currently charged with a Class B misdemeanor? Yes ◦ No ◦
6. Have you ever been found by a court to be incompetent by reason of mental defect? Yes ◦ No ◦
7. Were you discharged from the
military?
Yes
No
◦
◦
* If yes, have you received a dishonorable discharge, a bad conduct
discharge, or other than honorable discharge, from Armed Forces?
Yes
No
◦* If yes, submit a copy of
your DD-214
◦
8. Are you required to register as a sex offender, in the state of Texas or any other state? Yes ◦ No ◦
9. Federal law prohibits the Bureau from issuing a license to anyone who
is ineligible to work in the U.S. Are you a non-citizen?
Yes
No
◦
◦
*If yes, you must submit documentation of your federal employment
authorization or a copy of your permanent resident card.
10. I understand that, any pending charges or conviction referred to above require the submission of the appropriate court documentation, with this
application. Failure to report an arrest or conviction, later found by a fingerprint search, may result in denial or revocation of a license based
solely on the material misstatement of fact in this application.
11. I acknowledge that I have reviewed the eligibility criteria of Occupations Code §1702.113 and the definition of ‘conviction’ provided in §1702.371 and
Administrative Rule §35.1. In addition I acknowledge that I have reviewed the disqualifying offenses listed in Administrative Rules 35.42 and 35.46.
TO BE FILLED IN BY QUALIFIED MANAGER, MANAGER’S DESIGNEE OR OWNER
EMPLOYER INFORMATION
I hereby certify that the above applicant began employment in a position that requires this registration with my company on:
Applicant’s Date of Employment (MM/DD/YYYY) / /
I am requesting that the above applicant be issued a registration with my company as my employee.
Manager, Manager’s Designee or
Owner Printed Last Name
Printed
First Name
I verify that the information provided is true and correct, and I understand that this is an official Government record and that any false statement
made on this document or any other supplement provided to the Department may result in criminal prosecution.
Yes
No
Yes
No
◦
◦
◦
◦
Applicant Signature________________________________________________
Date____ /____ /________
Manager, Manager’s Designee or Owner Signature________________________________________________
Date____ /____ /________
This form and attachments can be forwarded by mail to:
Texas Department of Public Safety
Private Security MSC 0242
PO Box 15999
Austin, TX 78761-5999
PSB-04A (Rev. 12/2012) Page 2 of 2 FORM